Cerebrovascular Accident

CEREBROVASCULAR
ACCIDENT
PATIENT PRESENTATION-
1
 Mr.X,67yrs
 C/O weakness of RUL and RLL for 10 days
 C/O slurred speech for 10 days
 K/C/O T2 DM and on treatment
(uncontrolled)
 K/C/O systemic hypertension
 H/O lt leg diabetic foot below great toe
 H/O IHD
Assessment
 O/E conscious, obeying commands

 Speech dysarthria
 EOM-restricted
 Right facial palsy, gag reflex(N)
 Motor-hemiplegia
 Sensory-pain/touch impaired on right side
 DTR-++/++
 No neck stiffness
Investigations
 urine for c/s-no growth

 ECG: normal sinus rhythm
 Blood investigations
 Cholesterol-294(200)
 Triglyceride-129(150)
 HDL-25/11.8(60)
 LDL-201(100-159)
 MRI-Acute infarct in the medial aspect of
pons
 Age related atrophic changes
 BP-150/90 mmhg
 HR-98b/mt
 Spo2-100
 RR-30b/mt
 Temp-98.6°f
Medications
 Inj. Clexane 0.4ml s/c od

 Inj. Magnex forte 1.5gm in 100ml NS
IV bd
 Inj. Rantac 50mg IV bd
 Inj. H.Actrapid according to CBG s/c
tds
 T. Clopitab 75 mg RT 0-1-0
 T. Nicardia R 10 mg RT 1-0-1
2
 Mr. Y 60/m
 C/O neck pain x 4 days
 H/O fever x 2 days, low grade
 H/O one episode of giddiness x vomiting,
slurring of speech
 Pain and touch impaired on the right side
 Known HTN x 5yrs
 Lt eye ptosis, nystagmus-gaze evoked
ataxia, ltUL-4/5 RUL-5/5
Assessment
 BP-140/80 mmhg
 HR-92b/mt
 Spo2-99%
 RR-20breaths/mt
 Temp-98.6°f
Medications
 Inj. Fraseda 30 mg IV 100ml NS

 Inj. Rantac 50 mg IV
 Inj. Strocit 500 mg IV
 T Clopilet 75 mg p/o 0-1-0
 T Atorva 10 mg p/o 0-0-1
Investigations
 RBS-177 PPBS-141
 Na- 130
 Cholesterol-239
 Triglyceride-207
 HDL-31/7.7
 LDL-177
 MRI-Sub acute infarct
 Chronic infarct-rt cerebellum
 Carotid Doppler- Carotid grade II intimal
changes
 Non visualization of the mid and distal
portion of the basilar artery with very thin
caliber vertebral arteries.
 Vertebral Doppler study-lt vertebral minimal
flow, rt vertebral normal
3
 Mr.Z,40yrs/M
 Rt MCA infarct
 C/O weakness of LUL and LL for 4 days
 H/O slurring of speech
 Mouth deviating to rt side
 Chronic smoker and alcoholic-25yrs
 BP 150/80 mmhg
 Lt-UL:0/5,LL-0/5
 rt- UL:5/5,LL-5/5
Assessment
 GCS:15/15
 Pupils:2mm reacting to light
 Reflexes:++/++
 Alk phophatase:105
 Cholesterol-155
 Triglycerides-112
 HDL-35
 LDL-98
 CT brain: Acute infarct-Rt MCA territory
 MRI: Rt MCA infarct
Medications
 T.Nicardia R 10mg p/o tds

 T.clopilet 75 mg p/o od
 T.Statin 10 mg p/o od
 Inj Fraseda 30mg in 100ml Ns IV bd
 Inj Neksium 70 mg IV bd
What is a Stroke?
 “Stroke” is a term used to describe
neurological changes lasting more
than 24 hours caused by an
interruption in the blood supply to a
part of the brain. If the blood flow
ceases for an extended period of time,
the cerebral tissues involved die
causing permanent neurological
deficits.
15
CEREBRAL CIRCULATION
LOCATION
17
http://www.nlm.nih.gov/medlineplus/ency/imagepages/18009.htm
CLINICAL MANIFESTATIONS
COMMON EFFECTS OF A RIGHT HEMISPERIC STROKE
 Left visual field loss (homonymous hemianopsia)
 Dysphagia
 Usually retain language ability but may have difficulty producing speech
(dysarthria)
 Left-sided weakness (hemi paresis) or paralysis (hemiplegia)
 Sensory impairment
 Denial of paralysis, “forget” or “ignore” objects or people on their left side
(neglect)
 Impaired ability to judge spatial relationships (misjudge distances and depth
leading to falls, unable to guide hands to button a shirt, problems with directions
such as up / down, no concept of time)
 Impaired ability to locate and identify body parts
 Short-term memory impairments (difficulty remembering new information) and
apraxia (inability to carry out learned movement in the absence of weakness or
paralysis)
 Behavioral changes such as impaired judgement or insight into limitations,
overestimate physical ability, impulsivity, inappropriateness and difficulty
comprehending and expressing emotions
COMMON EFFECTS OF A LEFT HEMISPERIC
STROKE
 Right visual field loss (homonymous hemianopsia)

 Dysphagia
 May develop aphasia (loss of language including spoken, written,
reading and comprehension) but may also have dysarthria
 Right-sided weakness (hemiparesis) or paralysis
(hemiplegia)
 Sensory impairment
 Usually have normal perception
 Usually judgement is intact with good insight into
limitations
 Short-term memory impairments (difficulty remembering
new information) and apraxia (inability to carry out learned
movement in the absence of weakness or paralysis)
 Often develop a slow and cautious behavioral style. They need
frequent instructions and feedback to complete tasks
 Better able to comprehend and express emotions
TYPES OF STROKE
 Ischemic 80 - 84%
 Caused by blockage of the
artery resulting in reduction of
blood flow and cell death
 Include thrombotic, lacunar,
embolic cryptogenic
 CT scan negative until a few
days post stroke then
hypodense area - indicates
infarction
THROMBOTIC STROKE
 Atherosclerosis in cerebral arteries

 Similar to CAD – leading to MI
 Atherogenesis – decades long process
 In thrombotic stroke lumen of artery
narrows to point of obstruction
LACUNAR STROKE
 Atherosclerosis in
cerebral arteries
 Similar to CAD –
leading to MI
 Atherogenesis –
decades long process
 In thrombotic stroke
lumen of artery
narrows to point of
obstruction
EMBOLIC STROKE
 A clot travels from source outside of brain
 Encounters vessel with lumen narrow
enough to block its passage
 Clot lodges there, blocking blood flow
 Most common source - heart
 Common conditions - atrial fibrillation,
valvular disease, ventricular thrombi,
atherosclerosis of the proximal aorta
HEMORRHAGIC STROKE
 A clot travels from source
outside of brain
 Encounters vessel with lumen
narrow enough to block its
passage
 Clot lodges there, blocking
blood flow
 Most common source - heart
 Common conditions - atrial
fibrillation, valvular disease,
ventricular thrombi,
atherosclerosis of the proximal
aorta
EMERGENCY
MANAGEMENT
 Neurological vital
signs
 Blood pressure
 Glycemic control
 Control of body
temperature
 Oxygenation
 Hydration
HEMORRHAGIC STROKE
 Treatment based on the underlying cause of
the bleed and the extent of brain damage
 Treatment includes medication and surgical
intervention
 Management of  ICP with
antihypertensives or surgical evacuation of
hematoma
 In patients with ruptured aneurysm - clip or
embolization
Strategies to prevent a stroke
-Maintain a healthy weight - eat a reduced-fat diet
– Reduce alcohol intake to 1-2 drinks / day
– Exercise - 30 minutes 3-4 times / week
– Become smoke free and drug free
– Management of hypertension (ACE inhibitors)
– Management of heart disease (anticoagulants), diabetes
and hyperlipidemia (statins)
– Carotid endarterectomy may be indicated with stenosis
– Antiplatelets for plaque / clot formation
NURSING DIAGNOSIS
 Ineffective tissue perfusion r/t decreased cerebral
blood flow or cerebral edema
 Ineffective airway clearance r/t inability to raise
secretions ,ineffective cough
 Impaired physical mobility r/t neuromuscular and
cognitive impairment, decreased muscle strength
and control
 Impaired verbal communication r/t residual aphasia
 Risk for aspiration r/t inability to protect the airway
 Altered sensory perceptual r/t altered LOC,
impaired sensation and vision.
 Unilateral neglect r/t visual field deficit and
sensory loss on one side of the body
 Impaired urinary elimination r/t impaired
impulse to void or manage tasks of voiding
 Impaired swallowing r/t weakness or
paralysis of affected muscles
 Situational low self esteem r/t actual or
perceived loss of function.
NURSING MANAGEMENT
 Airway management/ventilator management
 Assessment and evaluation of neurologic
status to detect patient deterioration
 Blood pressure management
 General supportive care and prevention of
complications associated with:
– Dysphagia, HTN, hyperglycemia, dehydration,
malnourishment, fever, cerebral edema,
infection, and DVT, immobility, falls, skin care,
bowel and bladder dysfunction.
SIGNS OF ↑ ICP
 Early signs:  Late signs

– Decreased LOC – Pupillary
– Deterioration in abnormalities
motor function – Changes in
– Headache respiratory pattern
– Changes in vital – Changes in ABG’s
signs
 Airway management adequate O2 saturation
 Preventing increased ICP and providing supportive
care.
 Hourly vitals/neuros including ICP, CPP, CVP.
 Maintaining BP to ensure adequate CPP
 Seizure precautions
 Antibiotic prophylaxis
 Stabilization
 Prevention of complications
 Monitoring neuro status
 Family support and education
REHABILITATION
 Do with the patient not for the patient
 Management of impairment disability
or handicap
 Patient family and others
 Positioning
 Exercise
 Skin
 Communication
 Swallowing
 Elimination

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CEREBROVASCULAR

 O/E conscious, obeying commands

 urine for c/s-no growth

 Inj. Clexane 0.4ml s/c od

 Inj. Fraseda 30 mg IV 100ml NS

 T.Nicardia R 10mg p/o tds

 Right visual field loss (homonymous hemianopsia)

 Atherosclerosis in cerebral arteries

 Early signs:  Late signs

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